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Medical Insurance MEDICAL – TRADITIONAL PLAN (PPO) OVERVIEW The chart below reflects your responsibility for common services under the Traditional Plan. COVERED SERVICES IN NETWORK OUT-OF-NETWORK Deductible Individual (per Benefit Period) Family (per Benefit Period) $500 $1,000 $1,000 $2,000 Employee Medical Out-of-Pocket Limit Total of deductible, includes copays (office visits, urgent care, Emergency Dept.) and coinsurance $3,000 Individual $6,000 Family $6,000 Individual $12,000 Family Office Visit Primary Care Provider Specialist Mental Health Teladoc Telehealth (Acute and Behavioral Health) $25 $40 $10 30% after deductible 30% after deductible 30% after deductible N/A Preventive Care (Primary Preventive Diagnosis Only) for list see bcbsnc.com/preventive Primary Care Provider Specialist covered at 100% covered at 100% 30% after deductible 30% after deductible Urgent and Emergency Care Urgent Care Centers Emergency Room Visit (First Visit) Subsequent Emergency Room Visits Ambulance $25 $150 $450 covered at 100% $50 $150 $450 covered at 100% Inpatient Hospital Services 20% after deductible 30% after deductible Outpatient Services Facility Services Diagnostic Services Professional Services Facility Services Outpatient Mammography Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEGs and EKGs 20% after deductible covered at 100% covered at 100% 20% after deductible covered at 100% covered at 100% 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible Other Services Skilled Nursing Facility Home Health Care and Hospice Durable Medical Equipment, Prosthetics/Orthodontics CT scans, MRIs, MRAs and PET scans 20% after deductible 20% after deductible 20% after deductible covered at 100% 30% after deductible 30% after deductible 30% after deductible 30% after deductible CARY Benefits Handbook Page 9 NEWS FLASH You can save money by going to an in-network provider. To find an in-network provider use the BCBSNC Provider search COVERAGE Cary's plan covers the management, consultation, counseling, hormones, and surgical services for affirming gender identity and/or genetic transition (all related medical visits and laboratory services) and covers non- essential health benefits for hormone therapy, gender affirmation surgery, and related behavioral health services. QUESTIONS? About the plan, claims, lost ID cards, etc, contact the BCBSNC Customer Service Team 1-877-258-3334 MORE INFORMATION To help you further understand our two different medical plans, visit CNET. ? $10

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